Opioids in chronic pain management: is there a significant risk of addiction?

In the last decade there has been significant controversy about the appropriateness, efficacy, safety, and wisdom of treating chronic pain patients (CPPs) with opioids. Arguments against their use have included concerns about tolerance, dependence, addiction, persistent side effects, and interference with physical or psychosocial functioning. However, considerable experience and research with long-term cancer pain treatment suggests that in appropriately selected patients, opioids have a low morbidity, and a low addiction potential, and in addition to the primary analgesic action, can facilitate reduction in suffering, enhance functional activity level, and improve quality of life without significant risk of addictive behaviors. Some patients, however, are at risk. Risk factors for addiction are discussed in this article.

Management of chronic pain and control of long-term disability.

Chronic pain has become a major public health problem. Often, the availability of entitlement programs as well as psychosocial, occupational, and other nonmedical factors-rather than objective pathophysiology-are major contributors to disability. In this chapter, the authors discuss the relationship between impairment and disability and detail factors likely to predict or contribute to adverse clinical outcome and disability. Guidelines for disability prevention also are examined.

Are pain disorder and somatization disorder valid diagnostic entities?

Physicians and other clinicians who treat patients with chronic pain have doubtless recognized the interplay of various psychological and somatic variables in their patients' pain. Notwithstanding, there continues to be primary emphasis on the somatic factors, and continued neglect of the psychological. This article asserts that pain disorder and somatization disorder are indeed valid diagnostic entities, and that their respective incidence and prevalence are quite high both in patients with chronic pain and in the primary care setting. These diagnoses are compared and contrasted, along with the related diagnosis of the psychological factors affecting physical condition. Guidelines for assessment of these conditions are provided, as are recommendations as to when to refer patients for further psychological and psychiatric assessment and treatment.

Commentary: the potential for unintended consequences from public policy shifts in the treatment of pain.

Authors caution against possible unintended consequences of intractable pain treatment acts, suggesting that health care professionals look to the guidelines prepared by the Federation of State Medical Boards for an approach to this issue.

Evaluation and management of back pain: preventing disability.

Musculoskeletal pain has become a major public health problem with medical, occupational and socioeconomic implications. This paper reviews the problem of musculoskeletal back pain, impairment and implications for disability with specific reference to recent meta-analyses such as those performed by the Agency for Health Care Policy and Research (1994) and the IASP Task Force on Pain in the Workplace (1995). Data from these and other studies are consistent with our clinical findings suggesting that most cases of low back pain are idiopathic with an obscure etiology. As such they should be classified as non-specific low back pain (NSLBP) or back pain of undetermined etiology. The authors suggest that despite a paucity of objective findings many patients receive diagnoses difficult to justify and extensive diagnostic evaluation, some of which may be inappropriate and contribute to iatrogenic disability. Principles for appropriate diagnostic and therapeutic management are discussed with specific attention to risk factors likely to adversely influence treatment outcome and contribute to unnecessary disability.

Chronic pain and the disability epidemic.

Individuals with chronic pain frequently experience a complex and convoluted journey through the health care system that is often unrewarding for all involved. Excessive pain behavior may lead to unnecessary diagnostic testing or invasive procedures and result in iatrogenic complications and prolonged disability. Injured workers maintained on Worker's Compensation may be at increased risk for developing chronic pain syndromes unresponsive to conventional treatments. These individuals may have significant financial, psychosocial, and environmental reinforcement for maintenance of their disability and little incentive to return to work. Often there is no direct correlation between objective impairment and an individual's request for disability status. As job satisfaction and financial security diminish during our economic recession, the impact of the disability epidemic becomes more profound.

Pain treatment programs: do they return workers to the workplace?

Over the past decade multidisciplinary pain centers have provided a useful approach to the treatment of chronic pain syndromes that have been refractory to conventional treatments. The authors review the return-to-work rates of several pain centers, the factors influencing these rates, and the treatment interventions that are commonly employed.

The use of non-narcotic drugs and other alternatives for analgesia as part of a comprehensive pain management program.

Chronic pain remains an enigma which mystifies the most experienced clinicians. The traditional approaches to malignant pain employ narcotic analgesics, radiotherapy, surgical intervention, and chemotherapy. Within the context of a "therapeutic community" oriented pain unit, we attack this major public health problem differently. The use of non-narcotic analgesics, mood altering medications, various forms of psychotherapy (individual, group, family, gestalt, psychomotor) and peer pressure when used in conjunction with various physical modalities of treatment (including biofeedback, transcutaneous electrical nerve stimulator, physical therapy, whirlpool, massage, ice, heat, etc.) appear most efficacious. Frequently, the powerful tools of psychological medicine are taken for granted; yet, depression in the United States is widespread and so significantly complicates medical illness that any treatment program designed for pain patients must be holistic in its orientation if it is to be effective.

A holistic approach to pain rehabilitation: the Boston Pain Unit.

The traditional management of chronic pain has generally encompassed such options as bed rest, physical therapy, potent medication, surgery and nerve blocks. Experience has demonstrated the importance of the multi-disciplinary team in the approach to chronic pain, particularly when the pain problem has eluded diagnosis and/or adequate treatment via conventional techniques. In an attempt to widen the patient's choice of treatment modalities, the pain unit has emerged as a concept effective for the management of chronic pain. Frequently, chronic pain patients represent the treatment failures of the medical system. By the time of admission to a pain unit, their lives have become significantly disrupted and their pain problem complicated by depression, disability, financial stress, vocational difficulties, strains in interpersonal relationships, and a great loss of productivity.